Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LURASIDONE 20 MG TABLET [154462]

Facility

$5.11

Service Code	NDC 60687-747-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$4.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Cash Price	$2.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.09
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.81
Rate for Payer: Multiplan Commercial	$3.83

LURASIDONE 20 MG TABLET [154462]

Facility

$5.11

Service Code	NDC 60687-747-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.81
Max. Negotiated Rate	$4.09
Rate for Payer: Cash Price	$2.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.09
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.81
Rate for Payer: Multiplan Commercial	$3.83

LURASIDONE 20 MG TABLET [154462]

Facility

$0.80

Service Code	NDC 47335-578-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

LURASIDONE 40 MG TABLET [107668]

Facility

$0.80

Service Code	NDC 47335-684-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

LURASIDONE 40 MG TABLET [107668]

Facility

$5.13

Service Code	NDC 60687-758-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.08
Rate for Payer: Aetna of CA Government/Medicare	$3.08
Rate for Payer: Cash Price	$2.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.08
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$3.85

LURASIDONE 40 MG TABLET [107668]

Facility

$56.75

Service Code	NDC 63402-304-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$31.21
Max. Negotiated Rate	$45.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$34.05
Rate for Payer: Aetna of CA Government/Medicare	$34.05
Rate for Payer: Cash Price	$31.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$45.40
Rate for Payer: Health Smart Auto/Commercial	$34.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$34.05
Rate for Payer: LLUH Dept of Risk Management WC	$31.21
Rate for Payer: Multiplan Commercial	$42.56

LURASIDONE 40 MG TABLET [107668]

Facility

$56.75

Service Code	NDC 63402-304-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$31.21
Max. Negotiated Rate	$45.40
Rate for Payer: Cash Price	$31.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$45.40
Rate for Payer: Health Smart Auto/Commercial	$34.05
Rate for Payer: LLUH Dept of Risk Management WC	$31.21
Rate for Payer: Multiplan Commercial	$42.56

LURASIDONE 40 MG TABLET [107668]

Facility

$5.13

Service Code	NDC 60687-758-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.08
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$3.85

LURASIDONE 40 MG TABLET [107668]

Facility

$5.13

Service Code	NDC 60687-758-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.08
Rate for Payer: Aetna of CA Government/Medicare	$3.08
Rate for Payer: Cash Price	$2.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.08
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$3.85

LURASIDONE 40 MG TABLET [107668]

Facility

$5.13

Service Code	NDC 60687-758-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$4.10
Rate for Payer: Cash Price	$2.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.08
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Commercial	$3.85

LURASIDONE 40 MG TABLET [107668]

Facility

$0.80

Service Code	NDC 47335-684-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

MACITENTAN 10 MG TABLET [203952]

Facility

$518.20

Service Code	NDC 66215-501-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$285.01
Max. Negotiated Rate	$414.56
Rate for Payer: Cash Price	$285.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$414.56
Rate for Payer: Health Smart Auto/Commercial	$310.92
Rate for Payer: LLUH Dept of Risk Management WC	$285.01
Rate for Payer: Multiplan Commercial	$388.65

MACITENTAN 10 MG TABLET [203952]

Facility

$518.20

Service Code	NDC 66215-501-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$285.01
Max. Negotiated Rate	$414.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$310.92
Rate for Payer: Aetna of CA Government/Medicare	$310.92
Rate for Payer: Cash Price	$285.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$414.56
Rate for Payer: Health Smart Auto/Commercial	$310.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$310.92
Rate for Payer: LLUH Dept of Risk Management WC	$285.01
Rate for Payer: Multiplan Commercial	$388.65

MACITENTAN 10 MG TABLET [203952]

Facility

$518.20

Service Code	NDC 66215-501-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$285.01
Max. Negotiated Rate	$414.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$310.92
Rate for Payer: Aetna of CA Government/Medicare	$310.92
Rate for Payer: Cash Price	$285.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$414.56
Rate for Payer: Health Smart Auto/Commercial	$310.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$310.92
Rate for Payer: LLUH Dept of Risk Management WC	$285.01
Rate for Payer: Multiplan Commercial	$388.65

MACITENTAN 10 MG TABLET [203952]

Facility

$518.20

Service Code	NDC 66215-501-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$285.01
Max. Negotiated Rate	$414.56
Rate for Payer: Cash Price	$285.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$414.56
Rate for Payer: Health Smart Auto/Commercial	$310.92
Rate for Payer: LLUH Dept of Risk Management WC	$285.01
Rate for Payer: Multiplan Commercial	$388.65

MAFENIDE 85 MG/G TOPICAL CREAM [10478]

Facility

$1.53

Service Code	NDC 16571-723-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.92
Rate for Payer: Aetna of CA Government/Medicare	$0.92
Rate for Payer: Cash Price	$0.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Commercial	$1.15

MAFENIDE 85 MG/G TOPICAL CREAM [10478]

Facility

$1.53

Service Code	NDC 16571-723-60
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.92
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Commercial	$1.15

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.11

Service Code	NDC 5789663506
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 9999670013
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 6858500575
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 1000670013
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 6858500575
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.11

Service Code	NDC 5789663506
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 9999670013
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MAGNESIUM 64 MG (MAGNESIUM CHLORIDE) TABLET,DELAYED RELEASE [120162]

Facility

$0.10

Service Code	NDC 1000670013
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

Know your out-of-pocket cost for care.

All Charges